Liver transplantation for colorectal liver metastasis: Survival without recurrence can be achieved

The management of patients with colorectal liver metastases has improved significantly over the recent years. However, most patients still cannot undergo complete resection, generally because the location of the metastases within the liver prevents any radical management, which explains the interest for transplantation. The first structured attempts were performed in the 1980s with poor outcomes, in part due to a high proportion of death not related to the neoplastic disease. More recently, the group of Oslo has shown a 60% 5-year survival in 21 patients with colorectal metastases. Such a survival was better than the one expected on chemotherapy alone. However, 95% (20/21) of patients had cancer recurrence, most within the first 18 months after transplantation. At present, liver transplantation for colorectal metastases remains highly controversial. The potential for longterm disease-free survival needs to be explored, which is the aim of this multicentric collaborative retrospective study. A total of 12 patients (6 females/6 males) underwent liver transplantation for colorectal liver metastasis at centers affiliated to the “Compagnons H epatoBilaires” (see Supporting Information), an association of hepato-pancreato-biliary and transplant surgeons, most trained at the Paul Brousse Hospital, Paris, France, under the guidance of Professor H. Bismuth. Median age at transplant was 56 years (Table 1). Patients were managed in Lisbon (n5 8), Coimbra (n5 2), Paris (n5 1), and Geneva (n5 1) between October 1995 and October 2015 (date of transplant), and no other patient underwent transplantation for this indication at these respective transplant centers. Data collection was conducted according the relevant ethical standards at each institution. The location of the primary adenocarcinoma was the colon in 11 patients, and the rectum in 1 patient. Most primary cancers were T3 on pathology, and many presented between 1 and 3 involved—N1—lymph nodes (2 patients were N2 with more than 3 nodes involved; Table 1). For most patients, liver metastases (9/12) were diagnosed within 12 months after the diagnosis of the primary cancer and were considered as synchronous. When not diagnosed at the same time as the primary, liver metastases were discovered 4, 7, 19, 24, and 29 months after the primary. At the time of transplantation, patients presented a median of 9 liver metastases. Two had lesions> 5 cm, of 5.5 and 8 cm. Median carcinoembryonic antigen (CEA) level was 16.9 mg/L, and 1 patient had CEA> 200 mg/L, of 314mg/L. Most (11/12) patients received chemotherapy prior to transplantation. Chemotherapy included irinotecan and oxaliplatin in 9 (82%) patients, and a biological agent in 6 (cetuximab [cetux] in 2, bevacizumab [beva] in 3, and both agents in 1). Another patient was treated by intrahepatic chemotherapy prior to transplantation. All patients responded to chemotherapy, and none was in progression at the time of the transplantation. The decision to conduct a posttransplant Abbreviations: beva, bevacizumab; CEA, carcinoembryonic antigen; cetux, cetuximab; DFS, disease-free survival; NA, not available; O/I, oxaliplatin/irinotecan; RAPID, Resection And Partial Liver Segment 2/3 Transplantation With Delayed Total Hepatectomy; RFA, radiofrequency ablation.